Making Connexions: Enhancing the Therapeutic Potential of PatientClinician Relationships

The mysterious presence of suffering in human experience has terrified and fascinated people in all ages. Those who suffer empower healers to witness, explain, and relieve their suffering. An important component of healing, apart from the effect of any technology that is applied, derives from the relationship between the healer and the patient. In our own age, there is a perceived imbalance between the technical and the personal aspects of medical care. To improve the quality of our relationships with patients, we need a systematic understanding of what makes this relationship therapeutic. Such an understanding can provide guidance about what to do during medical encounters. The therapeutic nature of the patientclinician relationship has been described in many ways. Spiro [1] described empathythe capacity of the clinician to identify with the patient and to feel his painas the core dimension. Novack [2] and Irwin [3] called attention to the need for the patient and the clinician to construct a shared meaning of the illness and described specific behaviors that can contribute to the requisite process of exchange and negotiation. Cassell [4] suggested that the clinician lends her strength or wholeness to the patient whose own personhood is disrupted by the illness. Many writers, most notably Peabody [5], view caringthe personal interest that the clinician feels for the patientas the fundamental quality [5-7]. We have previously proposed that the therapeutic nature of the patientclinician relationship lies in its capacity to meet the needs of both the patient and the clinician for connection and meaning in their lives [8]. These needs are met through a transpersonal or spiritual dimension of medical care that is most readily recognized in occasional moments of particular closeness during medical encounters. These moments are often marked by a physiologic reaction, such as gooseflesh or a chill; by an immediacy of awareness of the patient's situation (as if experiencing it from inside the patient's world); by a sense of being part of a larger whole; and by a lingering feeling of joy, peacefulness, or awe. Such moments seem to be therapeutic for the patient and the clinician alike [8-10]. We proposed the term connexional (from the roots co [together] and nexus [a drawing together of parts to form a whole]) to describe the powerful and mutual experiences of shared understanding that characterize these moments. In this article, we describe interviewing techniques that we have found helpful in fostering connexional experiences. The strategies that we present were identified through a process of reflection on our personal experiences, followed by discussion and consensus development. Several of these approaches have been described by others in the more general contexts of patientdoctor relationships and psychiatric interviewing [2, 11]. Their value in promoting connexional experiences has not been systematically studied; we offer our experiences as a point of departure for further explorations by individual clinicians and researchers. It is important to remember that the techniques we describe are only tools; their use does not in itself constitute a moment of connection. Rather, they help to establish a favorable setting and an attitude of awareness within which such a moment might occur. So, we will not be considering how to do it so much as how to make it possible. We also present some of the potential risks in using these techniques to deepen the level of dialogue between patients and clinicians. We do this not to discourage the deeper exploration of the patientclinician relationship but to allow clinicians to proceed in a more informed and prepared manner. Strategies for Creating a Favorable Climate for Connexion Establishing Rapport The most basic element of connection is rapport. Rapport, in turn, depends on mutual respect and interest, expressed in words and behavior, between clinician and patient. This is primarily a personal, not a technical, endeavor; for no matter what techniques are used, the clinician must genuinely care about the patient. Nevertheless, specific interviewing techniques may convey caring and acceptance with particular effectiveness. Foremost among these communication strategies is the style of questioning. Eliciting the patient's full spectrum of concerns and allowing her to tell her story without unnecessary interruptions conveys the interviewer's interest without adding to the length of the visit [12, 13]. In contrast, an interview composed entirely of highly focused questions about symptoms, without consideration of their context or personal meaning, can easily create the impression that the interviewer is interested in only the disease and not in the patient. Recognition and explicit acknowledgment of emotional content in the patient's story is particularly important in establishing rapport. Recognition is not difficult when emotions are presented verbally (for example, I had a bad pain in my chest. I was so frightened.). More often, however, emotions are manifested less directly in the form of dramatic presentations (as when a patient states, eyes widened and hands clutching his chest, It was the worst pain I ever felt in my life. I thought I was going to die!). The patient's emotion is not mentioned by name, but it is clearly present nonetheless. Once an emotion is expressed, whether directly or indirectly, to continue on without acknowledging it (Did the pain travel to your neck?) may again make the interviewer seem uncaring. If we respond instead by acknowledging the emotion explicitly (It sounds like you were quite frightened. Tell me, did the pain travel to your neck?), the difference is negligible in terms of time but enormous in terms of making the patient feel cared for as a person. Other responses to emotions include support and partnership (for instance, It's important to me to understand your fears so we can address them together), legitimation (Who wouldn't be afraid after something like that?), and touch [14]. Various nonverbal techniques can promote rapport, such as observing and matching the patient's postures and gestures; respirations; tempo, volume, and pitch of speech; and language patterns [15]. The patient's nonverbal behavior can also call our attention to emotionally charged material (for example, sighs, voice qualities and pitch, posture, brimming of the eyes). Finally, rapport is established by a willingness to involve patients as equal partners throughout the interview, from negotiating an agenda at the beginning to negotiating a treatment plan and follow-up at the end [12, 16]. Silencing Internal Talk As we listen to the patient's story and as rapport deepens, we may experience a transition from hearing a description of his experiences to entering his life worldthe story changes from being abstract and distant to being immediate and felt, as if we were inside it. This is the essence of a connexional experience. Various techniques help us make this transition. First, as the patient begins to relate his story, it is necessary to silence our own internal talk [17]that part of consciousness that is already forming the next comment, question, or criticism, even as the patient is still speaking, distracting our attention away from his experience and from our own spontaneous responses. The diagnostic reasoning process, too, is a kind of internal talk that can interfere with our ability to listen; it can safely be deferred for a few moments until the patient's story is completed. Once we have listened carefully to the story, we can proceed with clarification and hypothesis testing. With internal talk silenced, we find more freedom in our awareness; we may shift attention frequently and continuously across various levels: the literal content of the patient's words; recurring themes; the use of metaphors and imagery; facial and body expressions; our own physical, mental, and emotional sensations; and so forth [18]. In this state of freely floating attention, we can have greater access to our own hunches, associations, and imagination, effectively harnessing our unconscious mind in the exploration of the patient's situation [19]. All of these observations are rich sources of hypotheses about what the patient is experiencing and the meaning that it holds. Accessing Unconscious Process The patient's unconscious process is our most important resource, provided we are alert to its methods of expression. Unconscious process will persistently urge the patient toward healing and growth and attempt to bring underlying problems to light, within the bounds of what the patient can accept consciously [20]. This principle, which is also the basis for free association in psychoanalysis, can lead both patient and doctor to discover connections between symptoms, feelings, and life events that may not have been consciously apparent to either of them at the start of the interview. To make use of unconscious process, we must begin with the assumption that no aspect of the patient's behavior is randomthat there is information to be gained from noticing how things are said, what is said, and what remains unsaid. Thus, by continually asking ourselves such questions as, Why is he telling me this? or Why did she use that particular phrase? we can identify clues pertaining to the deeper levels of the patient's story. I (DAM) was seeing a 56-year-old man in routine follow-up for hypertension and lingering depression that had responded poorly to medication. As usual, the patient was angry and belligerent about his treatment from his employer; his hostile comments about the company were peppered with references to being shot in the back, stabbed in the back, and raped from behind. I felt a sudden eerie, almost uncanny, feeling. When the patient subsequently described himself as a veteran, I encouraged him to describe his war experiences. The patient said, I don't know whether I should tell you a